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COVID-19 Health Information
Client Name
date
This document contains important information about your decision to receive services in light of the COVID-19 public health crisis. Please read and fill out this form carefully and let me know if you have any questions.
1. Have you had a fever in the last 24 hours of 100°F or above?
Yes
No
2. Do you now have, or have you recently had, any respiratory or flu symptoms (including fever, chills, sore throat, cough, muscle aches, or shortness of breath)?
Yes
No
3. Do you now have, or have you recently had, new loss of taste or smell, or new rashes or lesions?
Yes
No
4. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
Yes
No
5. Have you traveled anywhere outside of the state in the last two weeks?
Yes
No
Location
6. Have you had a new loss of sense of taste or smell?
Yes
No
Client Signature
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date
Parent or Guardian Signature (in case of a minor)
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date
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Client Signature
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Client Signature
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